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Henry S. Jennings III MD, FSCAI, FACC Vanderbilt University Medical Center Suresh R. Mulukutla MD, FSCAI, FACC University of Pittsburgh Medical Center Sunil V. Rao MD, FSCAI, FACC Duke University Medical Center To provide education to the referring physician on common pre- and post-procedural issues in patients undergoing invasive/interventional cardiac catheterization lab procedures To heighten awareness among referring physicians of the most recent Guidelines and Appropriate Use Criteria regarding diagnostic and interventional cardiac cath lab patients To foster a collaborative effort regarding our mutual patients in the important area of aftercare To highlight what SCAI is actively doing in the quality arena: SCAI-QIT Quality Champions Initiated late 2010 to bolster quality efforts in the cardiac cath lab environment SCAI Quality Committee oversight SCAI-QIT Physician Champions: currently more than 300 worldwide Series of SCAI-QIT Modules/Webinars: total of seven to date mid-2013 SCAI-QIT: Appropriate Use Criteria for Diagnostic Cath SCAI-QIT: What the Cath Lab Standards Update Has to Offer for Quality Improvement SCAI-QIT: Navigating the New Revascularization Appropriate Use Criteria SCAI-QIT: Navigating the Revised Guidelines to PCI SCAI-QIT: Defining Quality in the Cath Lab and Facility and Environmental Controls SCAI-QIT: Operator and Staff Requirements SCAI-QIT: Procedural Quality and Cath Lab Best Practices Appropriate Use Criteria/AUC Coronary Revascularization Overview/Elements Appropriate Use Criteria/AUC Diagnostic Cardiac Catheterization Overview/Elements Management Prior to and After Patient Referral to the Cardiac Cath Lab Dual Anti-Platelet Therapy/DAPT after PCI/Coronary Stenting Access Site Complications/Management Optimum Medical Therapy/OMT after PCI Diagnostic Testing after PCI Appropriate Use Criteria/AUC Coronary Revascularization Overview/Elements Appropriate Use Criteria/AUC Diagnostic Cardiac Catheterization Overview/Elements Management Prior to and After Patient Referral to the Cardiac Cath Lab Dual Anti-Platelet Therapy/DAPT after PCI/Coronary Stenting Access Site Complications/Management Optimum Medical Therapy/OMT after PCI Diagnostic Testing after PCI 30 years ago: Physicians relied upon experience and intuition to guide patient care 20 years ago: ACC/AHA/SCAI efforts began to provide Guidelines/standards of care ◦ Rely on evidence-based care/randomized trials ◦ If no evidence available, expert opinion ◦ Generally speaking, ignore costs Today: Appropriate Use Criteria (AUC) ◦ A supplement to ACC/AHA/SCAI guidelines ◦ Designed to improve efficient use of medical resources, to monitor utilization, to improve patient care and health outcomes Nat Rev Cardiol 2011;8(10) Approximately 600,000 PCIs are performed in the US each year, at a cost that exceeds $12 billion. Regional utilization variance has been noted by CMS. Patients who undergo PCI are exposed to risks of periprocedural complications and long-term bleeding and stent thrombosis. Given the cost and invasiveness of PCI, determining the extent to which PCI procedures are performed for appropriate and inappropriate indications could identify procedural overuse and areas for quality improvement and cost savings. Intended to assist patients and clinicians Not intended to diminish the difficulty or uncertainty of clinical decision making Cannot act as substitutes for sound clinical judgment and practice experience Allow assessment of utilization patterns for a test or procedure, including across providers Panel of 17 experts from various disciplines in cardiovascular disease; included noninvasive cardiologists, cardiac surgeons, others Limited number of most common clinical scenarios (>4,000 possible, 180 considered) First round voting with no group interaction Second round voting after review of first round data and discussion Scores from 1-9 generated for each indication 180 clinical scenarios involved different combinations of: Clinical Presentation ACS, Stable CAD, prior CABG Symptom severity CCS angina class Ischemia severity Low, intermediate, high on noninvasive functional testing High risk clinical features Left ventricular dysfunction, ventricular arrhythmia Intensity of anti-ischemic medical therapy Extent of coronary anatomical findings on angiography Significant 1-, 2-, 3-vessel coronary artery disease with or without disease of proximal LAD, LM or bypass graft *Scores 7-9: Appropriate, revascularization likely to improve health outcomes or survival *Scores 4-6: Uncertain, likelihood that revascularization would improve health outcomes or survival was considered uncertain *Scores 1-3: Inappropriate, revascularization unlikely to improve health outcomes or survival *Health outcomes: symptoms, functional status, and/or quality of life Patel, et al. JACC 2009; 53:530-553 Severity of Angina ASx, CCS Class I Patel, et al. JACC 2009; 53:530-553 LM + 3v CAD Anatomic Disease Clinical Presentation Stable Angina Max Medical Therapy CCS Class IV High Risk None No Sig. CAD Ischemia Tests/Prognostic Factors* STEMI None, Low Risk * CHF, DM, Low LVEF A U I Patel, et al. JACC 2012; 59: Patel, et al. JACC 2012; 59: Maximal Anti-Ischemic Medical Therapy: the use of at least 2 classes of therapies to reduce anginal symptoms Risk of Findings on Noninvasive Testing: ◦ Low-Risk (<1% annual cardiac mortality) ◦ Intermediate-Risk (1-3% annual cardiac mortality) ◦ High-Risk (>3% annual cardiac mortality) Patel, et al. JACC 2012; 59: Classification of Chest Pain Typical Angina (Definite): ◦ Substernal chest pain or discomfort ◦ Provoked by exertion or emotional stress ◦ Relieved by rest and/or nitroglycerin Atypical Angina (Probable): ◦ Lacks one of the characteristics of definite or typical angina Nonanginal Chest Pain: ◦ Meets one or none of the typical angina characteristics Patel, et al. JACC 2012; 59: Canadian Cardiovascular Society (CCS) Classification of Angina Pectoris CCS I: Ordinary physical activity does not cause angina, such as walking, climbing stairs. Angina occurs with strenuous, rapid, or prolonged exertion at work or recreation. CCS II: Slight limitation of ordinary activity. Angina occurs on walking more than 2 blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal condition. Patel, et al. JACC 2012; 59: Canadian Cardiovascular Society (CCS) Classification of Angina Pectoris CCS III: Marked limitations of ordinary physical activity. Angina occurs on walking one or two blocks on the level and climbing one flight of stairs in normal conditions and at a normal pace. CCS IV: Inability to carry on any physical activity without discomfort—anginal symptoms may be present at rest. Patel, et al. JACC 2012; 59: In general, coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia was felt to be appropriate. Revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy were viewed less favorably. Patel, et al. JACC 2012; 59: All physicians/facilities will not have 100% of their revascularization procedures deemed appropriate. May be clinical situations in which a use of coronary revascularization for an indication considered to be appropriate does not always represent reasonable practice, such that the benefit of the procedure does not outweigh the risks. Rating of scenario as inappropriate or uncertain should not preclude a provider from performing revascularization procedures when there are patient- and condition-specific data to support that decision. Patel, et al. JACC 2012; 59: When a procedure is classified as “Uncertain” it generally means one of two things: 1. There was not enough clinical information in the scenario. 2. There is not a substantial literature base upon which to make a firm recommendation There was not enough clinical information in the scenario. What we need from the referring physician: ◦ *Specifics about the outside stress test ◦ *Specifics about medical therapy and the character and severity of angina FFR, IVUS, and OCT evaluation has not yet been incorporated into defining appropriateness of PCI. This may change in next guideline update However, FFR, IVUS, and OCT should be utilized to evaluate moderate lesions defined as lesion severity of 40-70% to justify intervention Clearly document the use of FFR, IVUS, and OCT Recommendation COR LOE FFR to assess angiographic intermediate coronary lesions and to guide revascularization decisions in patients with SIHD IIa A IVUS for the assessment of angiographically indeterminate left main CAD IIa B IVUS after cardiac transplantation IIa B IVUS to determine the mechanism of stent restenosis IIa C IVUS for the assessment of non-left main angiographically intermediate stenoses IIb B IVUS for guidance of coronary stent implantation IIb B IVUS to determine the mechanism of stent thrombosis IIb C III – No Benefit C IVUS for routine lesion assessment when revascularization is not being contemplated Optical coherence tomography No Recommendations NCDR CathPCI is a registry of diagnostic cardiac catheterization and PCI data; more than 1000 US sites Provides reports containing practice patterns, demographics, and outcomes of diagnostic procedures and therapies Quarterly reports to institutions that are provider-specific; many parameters besides AUC data (fluoroscopy time, D2B, % normal cath rate, etc) Supported by ACCF and SCAI, among others Implemented the Appropriate Use Criteria 2009 JAMA, June 6, 2011 ACUTE PCIs 1.1% 11.6% NON-ACUTE PCIs One- or two-vessel CAD, no proximal LAD involvement, no prior CABG, CCS class I or II, low-risk stress test, no/minimal antiischemic therapy (39.6%) One- or two-vessel CAD, no proximal LAD involvement, no prior CABG, asymptomatic, intermediate-risk stress test, no/minimal antiischemic therapy (24.5%) One- or two-vessel CAD, no proximal LAD involvement, no prior CABG, asymptomatic, low-risk stress test, no/minimal anti-ischemic therapy (18.3%) Appropriate Use Criteria/AUC Coronary Revascularization Overview/Elements Appropriate Use Criteria/AUC Diagnostic Cardiac Catheterization Overview/Elements Management Prior to and After Patient Referral to the Cardiac Cath Lab Dual Anti-Platelet Therapy/DAPT after PCI/Coronary Stenting Access Site Complications/Management Optimum Medical Therapy/OMT after PCI Diagnostic Testing after PCI Suspected CAD: No prior noninvasive imaging Suspected CAD: Prior noninvasive imaging Patients with known prior obstructive CAD Evaluation of arrhythmias Pre-operative coronary evaluation Evaluation of valvular heart disease Evaluation of pericardial diseases Evaluation of cardiomyopathies Evaluation of pulmonary hypertension Suspected CAD: No prior noninvasive imaging Suspected CAD: Prior noninvasive imaging Patients with known prior obstructive CAD Evaluation of arrhythmias Pre-operative coronary evaluation Evaluation of valvular heart disease Evaluation of pericardial diseases Evaluation of cardiomyopathies Evaluation of pulmonary hypertension Assists us in determining need for right/left heart cath and coronary angiography in your patients Asymptomatic patients should generally not go directly to cath lab Stable pre-operative patients should rarely go directly to cath lab High probability CAD patients may go directly to diagnostic cath/coronary angiography, dependent on case specifics Appropriate Use Criteria/AUC Coronary Revascularization Overview/Elements Appropriate Use Criteria/AUC Diagnostic Cardiac Catheterization Overview/Elements Management Prior to and After Patient Referral to the Cardiac Cath Lab Dual Anti-Platelet Therapy/DAPT after PCI/Coronary Stenting Access Site Complications/Management Optimum Medical Therapy/OMT after PCI Diagnostic Testing after PCI I IIa IIb III I IIa IIb III I IIa IIb III Patients should be assessed for risk of contrast-induced AKI before PCI. Patients undergoing cardiac catheterization with contrast media should receive adequate preparatory hydration. In patients with CKD (Crcl <60 mL/min), the volume of contrast media should be minimized. I IIa IIb III No Benefit Administration of N-acetyl-L-cysteine is not useful for the prevention of contrast-induced AKI. *Additional points: Metformin: Discontinue 24 hours prior, check serum creatinine 48 hours after prior to restart ACEI: May need to be held in patients with low creatinine clearance/GFR I IIa IIb III I IIa IIb III No Benefit Patients with prior evidence of an anaphylactoid reaction to contrast media should receive appropriate steroid and antihistamine prophylaxis before repeat contrast administration. In patients with a prior history of allergic reactions to shellfish or seafood, anaphylactoid prophylaxis for contrast reaction is not beneficial. Statin-naive patients: I IIa IIb III Administration of a high-dose statin is reasonable before PCI to reduce the risk of peri-procedural MI. Patients on chronic statin therapy: I IIa IIb III Administration of a high-dose statin is reasonable before PCI to reduce the risk of peri-procedural MI. I IIa IIb III All patients should be evaluated for risk of bleeding before PCI. *Additional points: Coumadin held; INR should be < 1.6 Dabigatran/rivaroxaban held several days prior; dependent on GFR Unfractionated/low molecular weight heparin bridging likely necessary in patients with mechanical prosthetic valves Acknowledge significant bleeding risk of “triple therapy” Compared DAPT + anti-thrombotic (warfarin) for PCI/stent patients with need for ongoing anticoagulation (AF, mechanical valve, other) vs warfarin and clopidogrel alone (no ASA) Bleeding complications on “triple therapy” = 44.9% No significant difference in CV major endpoints that included stent thrombosis, MI, death Major reduction in bleeding complications in pts not taking ASA No confirmatory study/change in guidelines at this point Appropriate Use Criteria/AUC Coronary Revascularization Overview/Elements Appropriate Use Criteria/AUC Diagnostic Cardiac Catheterization Overview/Elements Management Prior to and After Patient Referral to the Cardiac Cath Lab Dual Anti-Platelet Therapy/DAPT after PCI/Coronary Stenting Access Site Complications/Management Optimum Medical Therapy/OMT after PCI Diagnostic Testing after PCI What about the newer agents prasugrel and ticagrelor, and is generic clopidogrel OK to use? Should I stop my patient’s proton pump inhibitor if they are taking clopidogrel? What do I do with my patient’s anti-platelet therapy during non-cardiac surgery? Does my patient benefit from DAPT > 1 year? What about that “black boxed” warning the FDA placed on the clopidogrel insert? Is my patient a “poor metabolizer”? What are “The Basics” about DAPT post-PCI?.... I IIa IIb III I IIa IIb III I IIa IIb III Patients already taking daily aspirin therapy should take 81 to 325 mg prior to PCI. Patients not on aspirin therapy should be given nonenteric aspirin 325 mg prior to PCI. After PCI, aspirin should be continued indefinitely. I IIa IIb III The duration of P2Y12 inhibitor therapy after stent implantation should generally be as follows: ◦ In patients receiving a stent (BMS or DES) during PCI for ACS, P2Y12 inhibitor therapy should be given for at least 12 months. Options include: clopidogrel 75 mg daily, prasugrel 10 mg daily, and ticagrelor 90 mg twice daily. ◦ In patients receiving a DES for a non–ACS indication, clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding. ◦ In patients receiving a BMS for a non-ACS indication, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks). I IIa IIb III After PCI, it is reasonable to use 81 mg per day of aspirin in preference to higher maintenance doses. I IIa IIb III If the risk of morbidity from bleeding outweighs the anticipated benefit afforded by a recommended duration of P2Y12 inhibitor therapy after stent implantation, earlier discontinuation (e.g., <12 months) of P2Y12 inhibitor therapy is reasonable. True ASA allergy vs. “allergy”/GI intolerance ASA “resistance” vs. noncompliance ASA desensitization feasible for the truly allergic Specific ASA dosage to be used varies depending on the clinical context and additional antiplatelet therapy I IIa IIb III Harm PCI with coronary stenting (BMS or DES) should not be performed if the patient is not likely to be able to tolerate and comply with DAPT for the appropriate duration of treatment based on the type of stent implanted. Additional consideration: Patient treatment compliance tools: SCAI Quality Committee actively evaluating What about the newer agents prasugrel and ticagrelor, and is generic clopidogrel OK to use? Ticlopidine: TTP risk, little used at present Clopidogrel: now generic and cost reduced; bioavailability issues/contaminants may be important but unknown; most studies done with original brand Prasugrel: contraindications include prior CVA; caution in age >75yo, weight <60kg Ticagrelor: ASA dose < 100mg Future agents: cangrelor, elinogrel, PAR-1 inhibitors Should I stop my patient’s proton pump inhibitor if they are taking clopidogrel? Nov. 17, 2009 – FDA alert: “New data show that when clopidogrel and omeprazole are taken together, the effectiveness of clopidogrel is reduced. Patients at risk for heart attacks or strokes who use clopidogrel to prevent blood clots will not get the full effect of this medicine if they are taking omeprazole.” PPIs are potent inhibitors of CYP2C19. Does co-administration of clopidogrel and PPIs lead to adverse patient outcomes? What effect will omeprazole have on clopidogrel metabolism in a patient with CYP2C19 *2/*2 ? Provided reassurance that there is no clinically relevant CV interaction between PPI’s and clopidogrel. Called into question the utility of platelet reactivity assays. I IIa IIb III I IIa IIb III I IIa IIb III No Benefit PPI should be used in patients with history of prior GI bleeding who require DAPT. PPI use is reasonable in patients with increased risk of gastrointestinal bleeding (advanced age, concomitant use of warfarin, steroids, nonsteroidal antiinflammatory drugs, H. pylori infection, etc.) who require DAPT. Routine use of a PPI is not recommended for patients at low risk of gastrointestinal bleeding, who have much less potential to benefit from prophylactic therapy. What do I do with this patient’s anti-platelet therapy during non-cardiac surgery? Two big considerations…. Timing: 6 weeks BMS, 12 months DES Advanced age Diabetes mellitus Renal dysfunction Low LVEF ACS @ presentation Circulation 2007, 116:e378-e382 Stenting of long/multiple lesions Bifurcational and ostial lesions Suboptimal stent deployment/apposition Overlapping stents Low Bleeding Risk Dermatologic Anterior eye chamber ◦ Cataract extraction Oral surgery/extractions EGD Colonoscopy without polypectomy Moderate Bleeding Risk Orthopedic surgery Abdominal procedures Thoracic procedures Urologic procedures Vascular procedures Intracranial Spinal column/neuraxis Specific procedures with high expected bleeding ◦ Highly vascular tumors ◦ Liver surgery/partial hepatectomy ?TURP For elective procedures, await completion of DAPT. ◦ 1 month minimum for BMS. ◦ 1 year for DES. For emergent or urgent surgeries, discuss with surgeon to consider if willing to operate on DAPT. If the bleeding risk is significant, then: ◦ Stop clopidogrel for as short a period as is reasonable. ◦ ASA 81 mg daily peri-procedurally. ◦ Restart clopidogrel as soon as possible post procedure. No proven benefit to “bridging” with either IIb/IIIa inhibitors or unfractionated heparin/LMWH Grines.JACC.2007;49:734-9 Does this patient benefit from prolonged dual antiplatelet therapy > 1 yr? The Answer: No data to necessarily support DAPT > 12 months for low anatomic and clinical risk patients; definitive answer not available What about that “black boxed” warning the FDA placed on the clopidogrel insert? Is my patient a “poor metabolizer”? Patients with CYP2C19 *2,*3 alleles metabolize clopidogrel poorly and are at higher risk for adverse events following PCI Inform health care professionals of tests available to identify genetic differences in CYP2C19 function Consider alternative antiplatelet strategies for clopidogrel in poor metabolizers FDA did NOT recommend routine genetic screening Clopidogrel must be metabolized to be active CYP2C19 is the one of the factors of concern CYP2C19 variants exist Homozygotes for the *2/*2 allele for CYP2C19 is an “at risk” category Heterozygote clinical implications are still unclear Simon T et al. N Engl J Med 2009;360:363-375 I IIa IIb III I IIa IIb III Genetic testing might be considered to identify whether a patient at high risk for poor clinical outcomes is predisposed to inadequate platelet inhibition with clopidogrel. When a patient predisposed to inadequate platelet inhibition with clopidogrel is identified by genetic testing, treatment with an alternate P2Y12 inhibitor (e.g., prasugrel or ticagrelor) might be considered. The routine clinical use of genetic testing to screen clopidogrel-treated patients undergoing PCI is not recommended. I IIa IIb III No Benefit I IIa IIb III I IIa IIb III I IIa IIb III No Benefit Platelet function testing may be considered in patients at high risk for poor clinical outcomes. In clopidogrel-treated patients with high platelet reactivity, alternative agents such as prasugrel or ticagrelor might be considered. The routine clinical use of platelet function testing to screen clopidogrel-treated patients undergoing PCI is not recommended. Appropriate Use Criteria/AUC Coronary Revascularization Overview/Elements Appropriate Use Criteria/AUC Diagnostic Cardiac Catheterization Overview/Elements Management Prior to and After Patient Referral to the Cardiac Cath Lab Dual Anti-Platelet Therapy/DAPT after PCI/Coronary Stenting Access Site Complications/Management Optimum Medical Therapy/OMT after PCI Diagnostic Testing after PCI Femoral ◦ ◦ ◦ ◦ Hematoma vs. Pseudoaneurysm AV fistula Infection Limb ischemia *Differential: cholesterol embolism syndrome Radial ◦ Sterile local proliferation reaction Vascular Closure Devices ◦ Temporal limitation on repeat access Antiplatelet agents Anticoagulation Large sheath size > 8F Age > 65 years Obesity Poor post-procedural compression Hemodialysis Simultaneous artery/vein catheterization Hypertension Peripheral arterial disease Complex interventions Low or high puncture sites PTFE covered stent in femoral artery to exclude pseudoaneurysm Ultrasound probe compression Ultrasound-guided thrombin injection* Open vascular surgical repair/ligation Appropriate Use Criteria/AUC Coronary Revascularization Overview/Elements Appropriate Use Criteria/AUC Diagnostic Cardiac Catheterization Overview/Elements Management Prior to and After Patient Referral to the Cardiac Cath Lab Dual Anti-Platelet Therapy/DAPT after PCI/Coronary Stenting Access Site Complications/Management Optimum Medical Therapy/OMT after PCI Diagnostic Testing after PCI 1. 2. 3. 4. 5. 6. 7. Tobacco Cessation BP Control: < 140/90 or < 130/80 if DM or CKD. Lipid Management: LDL < 100, if trig > 200, non-HDL should be < 130 mg/dl. Physical Activity: 30 min. at least 5days / week. Weight Management: BMI 18.5-24.9 kg/m2. Waist circumference: Men < 40 in, Women < 35 in. DM Management: HbA1c < 7%. Aspirin: ASA 162-325 mg / day x 1 m post BMS, 3 mo post SES, 6 mo post PES, then ASA 75-162 mg / day. King et al. JACC 2008. 51: p. 172-209 8. Clopidogrel: ◦ DES Clopidogrel 75 mg / day x 12 m. ◦ BMS Clopidogrel 75 mg / day x 1 m minimum and ideally up to 12 m. Minimum of 2 wks if increased bleeding risk. 9. Warfarin: INR 2-3 for AF / flutter. ◦ If warfarin, clopidogrel, and ASA required, then INR of 22.5, ASA 75-81 mg, and clopidogrel 75 mg / day 10. ACE-I: Use if ◦ LVEF < 40% ◦ HTN, DM, or CKD. 11. ARB: use if intolerant of ACE-I plus ◦ CHF or LVEF < 40% or if HTN is present. 12. 13. 14. Aldosterone blockade: use if post-MI on an ACE-I and Bblocker, LVEF < 40% and have DM or CHF Beta blockers: Use if pt has had an MI, ACS, or LV dysfunction. Annual Influenza Vaccination I IIa IIb III Medically-supervised exercise programs (cardiac rehabilitation) should be recommended to patients after PCI, particularly for moderate- to high-risk patients for whom supervised exercise training is warranted. Appropriate Use Criteria/AUC Coronary Revascularization Overview/Elements Appropriate Use Criteria/AUC Diagnostic Cardiac Catheterization Overview/Elements Management Prior to and After Patient Referral to the Cardiac Cath Lab Dual Anti-Platelet Therapy/DAPT after PCI/Coronary Stenting Access Site Complications/Management Optimum Medical Therapy/OMT after PCI Diagnostic Testing after PCI Ferromagnetism is the issue None of the currently or previously utilized coronary stents approved by FDA are significantly ferromagnetic Device manufacturer caveats Levine et al, Circulation. 2007;116:2878-2891 Anatomic information alone; no physiologic data Pre-existing stents (especially with extensive calcification) significantly limit assessment of luminal narrowing of the involved vessel segment I IIa IIb III In patients entering a formal cardiac rehabilitation program after PCI, treadmill exercise testing is reasonable. Routine, periodic stress testing of asymptomatic patients after PCI without specific clinical indications should not be performed. Possible additional considerations: I IIa IIb III No Benefit ◦ Unprotected LMCA stent ◦ “Last remaining vessel” stent ◦ Silent ischemia/SCD as initial presentation Accreditation for Cardiovascular Excellence/ACE certification Current AUC App for coronary revascularization Future AUC App for diagnostic catheterization Regional SCAI-QIT sponsored educational sessions for referring physicians “Choosing Wisely” effort Cooperative effort of ABIM with multiple subspecialty societies, including ACP and AAFP ACC and SCAI, in addition to many other subspecialty organizations, partnering in these efforts as well List of five commonly used, but not always necessary, tests and procedures SCAI recommendations at www.scai.org